Surgical Tactics for Left-Sided Stab-Cut Thoracoabdominal Injuries

The dissertation is devoted to the development and substantiation of an improved surgical tactic for left-sided stab-cut thoracoabdominal injuries — one of the most severe and frequently encountered categories of penetrating trauma affecting the abdominal cavity and thoracic cavity. The research aims to enhance the effectiveness of diagnosis and treatment for this category of patients through the implementation of objective scoring systems for assessing injury severity, the application of video thoracoscopy, and intra-abdominal pressure monitoring. The study analyses traditional and modern approaches to the management of patients with thoracoabdominal injuries, identifies shortcomings in existing tactics, and justifies the necessity of a differentiated approach to the selection of the surgical method depending on the objective severity of the injuries. The practical significance of the work consists in the development of an optimal diagnostic and therapeutic tactic that reduced mortality, decreased the number of diagnostic and therapeutic thoracotomies, shortened the number of postoperative complications, and reduced hospitalization duration. The results of the research have been implemented in the practice of surgical departments of a city clinical hospital and are used in the educational process of the medical academy.

Trauma is currently the leading cause of death, as well as disability among persons of active working age. Posttraumatic thoracoabdominal injuries occupy a special place in the structure of peacetime injuries. The problem of treating patients with thoracoabdominal injuries remains relevant at present due to their increasing frequency, the complexity of timely diagnosis, and the choice of a rational surgical tactic, especially given the constant increase in the relative number of such patients in the structure of general surgical patients [5, 20, 35]. Left-sided thoracoabdominal injuries are distinguished by the greatest severity of damage and multiplicity of lesions, occurring 2–2.5 times more frequently than right-sided ones [3, 27, 41, 135]. Despite the prevalence of left-sided stab-cut thoracoabdominal injuries, many questions of diagnosis and surgical treatment remain unresolved. Meanwhile, the correct preoperative diagnosis and the sequence of actions have a decisive significance for the success of treatment in this category of patients.

The traditional surgical tactic and the «individual» approach to the injured with TAIs, recommended in most publications, on the one hand lead to a large number of unjustified thoracotomies, and on the other hand, to unjustifiably prolonged «active» observation of the patient with delay of the necessary operation [3, 49, 90].

The appearance of video thoracoscopy (VT) has largely changed the diagnostic and therapeutic process in penetrating chest injuries and TAIs in particular. Video thoracoscopy in chest injuries possesses highly informative diagnostic and broad therapeutic capabilities [17, 18, 45, 174]. However, despite proven advantages of its application, the method has not gained wide spread in practical healthcare to date. The application of video thoracoscopy in the diagnosis and treatment of TAIs has been insufficiently studied. There is no unified algorithm of diagnostic and therapeutic actions for TAIs. In most publications, the assessment of the severity of the patients' condition is produced subjectively, and modern classifications are insufficiently oriented toward determining a specific surgical tactic depending on the objective (scoring) assessment of the severity of injuries at admission. The above problems and unresolved questions provide grounds to consider further development of this problem to be relevant.

The goal of the work is to improve the outcomes of treatment of patients with left-sided stab-cut thoracoabdominal injuries. Tasks:

1. To determine the feasibility of using a scoring system for assessing the severity of the patients' condition to determine the surgical tactic for stab-cut TAIs.

2. To study the diagnostic and therapeutic capabilities of video thoracoscopy in left-sided stab-cut thoracoabdominal injuries.

3. To develop a surgical tactic for left-sided stab-cut TAIs depending on the severity of patients (according to the scoring system) and the capabilities of video thoracoscopy.

4. To compare the results of traditional and developed tactics for the treatment of TAIs and, based on the obtained data, to select the optimal diagnostic and therapeutic tactic.

5. To assess the necessity of intra-abdominal pressure monitoring in the postoperative period in order to predict the probability of the development of intra-abdominal complications.

Scientific novelty.

A surgical tactic for the treatment of left-sided stab-cut thoracoabdominal injuries has been developed with a differentiated approach depending on the objective assessment of the severity of injuries at admission. The role and place of video thoracoscopy in the algorithm of diagnosis and treatment of left-sided stab-cut thoracoabdominal injuries have been established. The necessity of applying intra-abdominal pressure monitoring to predict the development of intra-abdominal complications in left-sided stab-cut thoracoabdominal injuries has been demonstrated for the first time.

Practical significance.

The feasibility of determining the severity of the patients' condition using integrated (scoring) scale systems to determine indications for the possibility of applying video thoracoscopy in the diagnosis and treatment of each specific patient has been revealed. Based on the method of video thoracoscopy and the objective assessment of the severity of the patients' condition, the traditional surgical tactic for left-sided stab-cut thoracoabdominal injuries has been reconsidered. The developed new diagnostic and therapeutic tactic made it possible to reduce mortality, decrease the number of diagnostic and therapeutic thoracotomies and cases of inadequate choice of the sequence of access, reduce the number of postoperative complications, and shorten hospitalization and treatment duration.

Implementation of the research results in practice.

The tactical guidelines have been implemented in the work of the surgical departments of City Clinical Hospital No. 7 in Moscow.

The results of the research are used in lectures and practical classes for students of the Department of Hospital Surgery No. 2 of I.M. Sechenov Moscow Medical Academy. The results of the work were reported at:

1. The All-Armenian International Surgical Congress, October 1–3, 2004, Yerevan, Republic of Armenia.

2. The First Congress of Moscow Surgeons «Emergency and Specialized Surgical Care», May 19–21, 2005, Moscow.

3. The International Surgical Congress «New Technologies in Surgery», October 5–7, 2005, Rostov-on-Don.

Six printed scientific works have been published on the topic of the dissertation.

The dissertation was tested at a joint scientific conference of the Department of Hospital Surgery No. 2 of the Faculty of Postgraduate Medical Education at I.M. Sechenov Moscow Medical Academy, the Liver Surgery Department of the Research Centre of I.M. Sechenov Moscow Medical Academy, and surgeons of the surgical departments of City Clinical Hospital No. 7 in Moscow.

The main provisions submitted for defense:

1. The use of the objective assessment of the severity of patients according to the scoring system for patients with TAIs and a differentiated approach determine the urgent surgical tactic.

2. Video thoracoscopy is a necessary method in the diagnostic and therapeutic algorithm for left-sided stab-cut thoracoabdominal injuries.

3. Intra-abdominal pressure monitoring in patients with TAIs allows prediction of postoperative intra-abdominal complications.

Volume and structure of the work.

The dissertation is presented on pages of typed text and consists of an introduction, 4 chapters, conclusion, conclusions, practical recommendations, and a list of references. The bibliography includes 179 sources (71 domestic and 108 foreign authors). The dissertation is illustrated with 24 tables and 14 figures.